Kidney care in low- and middle-income countries.

Optimal kidney care requires a trained nephrology workforce, essential healthcare services, and medications. This study aimed to identify the access to these resources on a global scale using data from the multinational survey conducted by the International Society of Nephrology (ISN) (Global Kidney Health Atlas (GKHA) project), with emphasis on developing nations. For data analysis, the 125 participating countries were sorted into the 4 World Bank income groups: low income (LIC), lower-middle income (LMIC), upper-middle income (UMIC), and high income (HIC). A severe shortage of nephrologists was observed in LIC and LMIC with < 5 nephrologists per million population. Many LIC were unable to access estimated glomerular filtration rate (eGFR) and albuminuria (proteinuria) tests in primary-care levels. Acute and chronic hemodialysis was available in most countries, although acute and chronic peritoneal dialysis access was severely limited in LIC (24% and 35%, respectively). Most countries had kidney transplantation access, except for LIC (12%). HIC and UMIC funded their renal replacement therapy (RRT) and renal medications primarily through public means, whereas LMIC and LIC required private and out-of-pocket contributions. In conclusion, this study found a huge gap in the availability and access to trained nephrology workforce, tools for diagnosis and management of CKD, RRT, and funding of RRT and essential medications in LIC and LMIC.

Assessment of Global Kidney Health Care Status.

Importance: Kidney disease is a substantial worldwide clinical and public health problem, but information about available care is limited. Objective: To collect information on the current state of readiness, capacity, and competence for the delivery of kidney care across countries and regions of the world. Design, Setting, and Participants: Questionnaire survey administered from May to September 2016 by the International Society of Nephrology (ISN) to 130 ISN-affiliated countries with sampling of key stakeholders (national nephrology society leadership, policy makers, and patient organization representatives) identified by the country and regional nephrology leadership through the ISN. Main Outcomes and Measures: Core areas of country capacity and response for kidney care. Results: Responses were received from 125 of 130 countries (96%), including 289 of 337 individuals (85.8%, with a median of 2 respondents [interquartile range, 1-3]), representing an estimated 93% (6.8 billion) of the world's population of 7.3 billion. There was wide variation in country readiness, capacity, and response in terms of service delivery, financing, workforce, information systems, and leadership and governance. Overall, 119 (95%), 95 (76%), and 94 (75%) countries had facilities for hemodialysis, peritoneal dialysis, and kidney transplantation, respectively. In contrast, 33 (94%), 16 (45%), and 12 (34%) countries in Africa had facilities for hemodialysis, peritoneal dialysis, and kidney transplantation, respectively. For chronic kidney disease (CKD) monitoring in primary care, serum creatinine with estimated glomerular filtration rate and proteinuria measurements were reported as always available in only 21 (18%) and 9 (8%) countries, respectively. Hemodialysis, peritoneal dialysis, and transplantation services were funded publicly and free at the point of care delivery in 50 (42%), 48 (51%), and 46 (49%) countries, respectively. The number of nephrologists was variable and was low (<10 per million population) in Africa, the Middle East, South Asia, and Oceania and South East Asia (OSEA) regions. Health information system (renal registry) availability was limited, particularly for acute kidney injury (8 countries [7%]) and nondialysis CKD (9 countries [8%]). International acute kidney injury and CKD guidelines were reportedly accessible in 52 (45%) and 62 (52%) countries, respectively. There was relatively low capacity for clinical studies in developing nations. Conclusions and Relevance: This survey demonstrated significant interregional and intraregional variability in the current capacity for kidney care across the world, including important gaps in services and workforce. Assuming the responses accurately reflect the status of kidney care in the respondent countries, the findings may be useful to inform efforts to improve the quality of kidney care worldwide.

Nephrology training curriculum and implications for optimal kidney care in the developing world.

An effective workforce is essential for delivery of high-quality chronic disease care. Low-income nations are challenged by a dearth and/or maldistribution of an essential workforce required for all chronic disease care including chronic kidney disease (CKD). Nephrology education and training in developed countries have grown at pace with the technological advancement in the practice of medicine in order to meet the standards required of kidney health professionals towards high-quality, patient-centered medical care. The standards designed by institutions and/or professional societies, such as Royal Colleges and Medical Councils in high-income nations with well-developed health systems and infrastructures, are often not easily translatable to issues critical to nephrology practice in low-income nations. Little or no guidance is provided on common nephrological issues of regional nature or pertaining to ethnic minorities and disadvantaged groups living in those countries. There is an emergent need for a training curriculum that meets the needs and peculiarities of the developing nations, and this needs to leverage on the existing and well-validated systems of training across the globe. We evaluated nephrology training programs across 25 upper-middle and high-income nations to identify best practices and opportunities for adoption in low-income nations. We reviewed training guidelines from major professional societies on content and process of training. There are similarities and differences in structure, content, and process of training programs across countries, and there are clearly adoptable concepts/frameworks for application in low-income nations. We provide recommendations and a strategic plan for the future focus of nephrology training in the developing world to align with current trends in technological advancement and development as well as the need for emphasis on prevention of CKD. The essential competencies (patient- and population--based) required of a nephrologist in a developing world setting are outlined with practical measures and an action plan for adoption.

Prevalence of malignant or possibly malignant renal masses among homogeneous low-attenuation masses that are too small to characterize at computed tomography.

BACKGROUND: Homogeneous low-attenuation renal masses that are too small to characterize (tstc) are considered clinically insignificant; however, based primarily on expert opinion. OBJECTIVE: To determine the prevalence of malignant or possibly malignant masses among homogeneous low-attenuation renal masses that are tstc. MATERIALS AND METHODS: This retrospective cross-sectional study evaluated 75 patients with 104 tstc who underwent renal CT and MRI between Jan 2016 and Jul 2022. Low-attenuation renal masses measuring < 1 cm in size were identified and, independently evaluated by two blinded radiologists measuring attenuation (Hounsfield Units, HU) at non-contrast enhanced CT (NECT) and nephrographic phase contrast-enhanced (CE)-CT when possible. Reference standard for benign cyst was MRI and for other renal masses was pathology or MRI showing enhancement. RESULTS: Average tstc size was 6 ± 2 (range 2-10) mm. Considering only incidental tstc (CT performed for another reason), 100% (98/98, 95%CI 96-100%) tstc were benign. Overall, considering both incidental and tstc referred for further characterization, there were 94% (98/104; 95% Confidence Intervals [CIs] 88-98%) benign cysts and 6% (6/104; 95%CI 2-12%) other masses (1 Bosniak 2F cystic mass, 2 probable renal cell carcinoma (RCC), three metastases). Pseudoenhancement, attenuation change > 10 HU or > 20 HU, was present in 29% (15/59) and 12% (7/59) benign cysts. All six other masses enhanced by > 20 HU. CECT threshold of ≤ 30 HU correctly classified 62% of benign cysts (61/98). All six other masses measured > 30 HU at CECT. CONCLUSION: The prevalence of malignant or possibly malignant renal masses among homogeneous low-attenuation too small to characterize masses among incidental tstc masses is near zero. Attenuation measurements misclassify a substantial proportion of these cysts, likely due to their small size.

Real-time computerized video enhancement for minimally invasive fetoscopic surgery.

BACKGROUND: The only definitive treatment for twin-to-twin transfusion syndrome is minimally invasive fetoscopic surgery for the selective coagulation of placental blood vessels. Fetoscopic surgery is a technically challenging operation, mainly due to the poor visibility conditions in the uterine environment. We present the design of an algorithm for the computerized enhancement of fetoscopic video and show that the enhanced video increases the ability of human users to identify blood vessels within fetoscopic video rapidly and accurately. METHODS: A computer algorithm for the enhancement of fetoscopic video frames was created. First, optical fiber artifacts were removed via a modification of unsharp masking. Second, image contrast was increased via Contrast Limited Adaptive Histogram Equalization (CLAHE). Third, the effect of contrast enhancements on stationary features was removed by normalizing to a windowed mean of the video frames. Fourth, color information was reincorporated by combining the mean-normalized result with the unnormalized contrast enhanced image using the soft light blending algorithm. Medical trainees (n = 16) were recruited into a study to validate the algorithm. Subjects were shown enhanced or unenhanced fetoscopic video frames on a screen and were asked to identify whether a randomly placed marker fell on a blood vessel or on background. The accuracy of their responses was recorded. RESULTS: On the subset of images where subjects had the lowest mean accuracy in identifying the placement of the marker, subjects performed better when viewing video frames enhanced by the computer (accuracy 74.27%; SE 0.97) than when viewing unenhanced video frames (accuracy 63.78%; SE 2.79). This result was statistically significant (p < 0.01). CONCLUSION: Real-time computerized enhancement of fetoscopic video has the potential to ease the readability of video in poor lighting conditions, thus providing a benefit to the surgeon intraoperatively.

Global coverage of health information systems for kidney disease: availability, challenges, and opportunities for development.

Development and planning of health care services requires robust health information systems to define the burden of disease, inform policy development, and identify opportunities to improve service provision. The global coverage of kidney disease health information systems has not been well reported, despite their potential to enhance care. As part of the Global Kidney Health Atlas, a cross-sectional survey conducted by the International Society of Nephrology, data were collected from 117 United Nations member states on the coverage and scope of kidney disease health information systems and surveillance practices. Dialysis and transplant registries were more common in high-income countries. Few countries reported having nondialysis chronic kidney disease and acute kidney injury registries. Although 62% of countries overall could estimate their prevalence of chronic kidney disease, less than 24% of low-income countries had access to the same data. Almost all countries offered chronic kidney disease testing to patients with diabetes and hypertension, but few to high-risk ethnic groups. Two-thirds of countries were unable to determine their burden of acute kidney injury. Given the substantial heterogeneity in the availability of health information systems, especially in low-income countries and across nondialysis chronic kidney disease and acute kidney injury, a global framework for prioritizing development of these systems in areas of greatest need is warranted.

Global access of patients with kidney disease to health technologies and medications: findings from the Global Kidney Health Atlas project.

Access to essential medications and health products is critical to effective management of kidney disease. Using data from the ISN Global Kidney Health Atlas multinational cross-sectional survey, global access of patients with kidney disease to essential medications and health products was examined. Overall, 125 countries participated, with 118 countries, composing 91.5% of the world's population, providing data on this domain. Most countries were unable to access eGFR and albuminuria in their primary care settings. Only one-third of low-income countries (LICs) were able to measure serum creatinine and none were able to access eGFR or quantify proteinuria. The ability to monitor diabetes mellitus through serum glucose and glycated hemoglobin measurements was suboptimal. Pathology services were rarely available in tertiary care in LICs (12%) and lower middle-income countries (45%). While acute and chronic hemodialysis services were available in almost all countries, acute and chronic peritoneal dialysis services were rarely available in LICs (18% and 29%, respectively). Kidney transplantation was available in 79% of countries overall and in 12% of LICs. While over one-half of all countries publicly funded RRT and kidney medications with or without copayment, this was less common in LICs and lower middle-income countries. In conclusion, this study demonstrated significant gaps in services for kidney care and funding that were most apparent in LICs and lower middle-income countries.

Effectiveness of Multifaceted Care Approach on Adverse Clinical Outcomes in Nondiabetic CKD: A Systematic Review and Meta-analysis.

INTRODUCTION: The risk of major adverse events associated with chronic kidney disease (CKD) could potentially be reduced with effective medical interventions. The impact of multifaceted interventions as compared with usual care in patients with nondiabetic CKD is unclear. We performed a systematic review to analyze the impact of multifaceted interventions on reducing the risk of major adverse events in this population. METHODS: Systematic review and meta-analysis. We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases for medical literature published up to November 2016. Published original studies and abstracts were reviewed that reported on adult patients in a community or specialty care setting, with 2 or more CKD risk factors, treated with a combination of more than 2 interventions. We included randomized controlled trials, observational studies, and systematic reviews. Studies focused on diabetic patients were excluded. The intervention was defined as a treatment with a combination of 2 or more interventions compared with the usual care. The outcomes were defined as a reduction in the risk of adverse clinical outcomes (renal replacement therapy, all-cause hospitalizations, all-cause and cardiovascular mortality, cardiovascular events) as primary outcomes. Secondary outcomes were optimal risk factor control (attaining guideline concordant blood pressure, reduction of proteinuria, smoking cessation). RESULTS: Five of the 5846 unique citations from our initial literature search met our study criteria. All identified studies reported on patients with CKD and their management. In comparison with usual care, multifaceted interventions tended to reduce all-cause mortality (risk ratio: 0.81, 95% confidence interval: 0.63-1.03) and were associated with a lower risk of progression to kidney failure requiring dialysis (risk ratio: 0.57, 95% confidence interval: 0.35-0.94). Multifaceted interventions were not associated with reducing risk of all-cause hospitalizations (risk ratio: 0.93, 95% confidence interval: 0.71-1.23) or improved blood pressure control (mean difference: -0.48, range: -2.5 to 1.55 mm Hg). DISCUSSION: Multifaceted interventions targeting multiple risk factors tended to reduce the risk of all-cause mortality and reduced the risk to progress to end-stage kidney failure in patients with CKD. There is a need for high-quality studies that can rigorously evaluate a set of interventions targeting multiple domains of CKD management in the population with nondiabetic CKD due to paucity of data in the current published literature.